【纲】仲景曰。病发于阳而反下之。热入。因作结胸。若不结胸。但头汗出。余无汗。至颈而
还。小便不利。身必发黄也。
【目】陈士铎曰。伤寒变为结胸者。以伤寒火邪正炽。急与饮食。胃中得食。茹而不出。他脏
因胃中有食。群起而争。其势猖狂。必当以变法治之。急用栝蒌一枚。槌碎。入甘草一钱。同煎服。
夫栝萎乃陷胸之胜物。平人服之。必至心如遗落。然惟食结在胸。非硝、黄、枳、朴、槟榔等可
祛。必得栝蒌始能陷之。尤恐其过于下也。可加甘草留之。使不至十分推荡。此变症而用变法。真
胜于用正也。
张云岐曰。不发汗而反下之。热反内陷。寒气随热而入。入于胸必结。瘀热在里故也。
【纲】仲景曰。结胸无大热。但头微汗出者。此为水结在胸胁也。大陷胸汤主之。
伤寒六七日。结胸热实。脉沉紧。心下痛。按之石硬者。大陷胸汤主之。结胸者。项亦强。如
柔痉状。下之则和。宜大陷胸丸。
【目】成无己曰。结胸虽为实邪。人皆知用陷胸汤丸下之。或脉浮大者。不可下。下则死。是
犹带表邪未全结实。下之重虚其里。邪深结则死。设或结胸形症悉具。而加烦躁者。尤为不治之疾。
【纲】仲景曰。病发于阳而反下之。热入。因作结胸。病发于阴而反下之。因作痞。所以成结胸
者。以下之太早故也。
【目】赵嗣真曰。不经下后而心下满者。则有吐下之殊。如病患手足厥冷。脉乍紧。邪结在胸
中。心中满而烦。饥不能食者。病在胸中。当须吐之。又脉浮而大。心下反硬。有热属脏者。攻之。
不令发汗。属腑者。不令溲数。此二条是也。或吐或攻。要在泄其邪气。若下后心下满者。又有
结胸痞之别。如阳明病。虽心下硬。又未可攻。经曰。阳明病心下硬满者。不可攻之。攻之利遂不
止者死。利止者愈。是邪气自表传里。至于心下。留结为实者。不可下。乃吐之可也。若未全为实
者。则不可下。故有此戒。又邪气在表。未应下而强下之。邪气乘虚结于心下。实者硬满而痛。
为结胸。虚者满而不痛。为痞。盖实邪留结。则为硬为痛。虚邪留滞。则但满而不硬痛也。
柯琴曰。阳指形躯。阴指胸中心下。非指阴经阴症。发阳发阴。俱指发热。结胸与痞。俱是热
症。作痞不言热入。热原发于里也。误下热不散。因而痞硬。不可以发阴作无热解也。若谓非热症。
泻心汤不得用黄芩、大黄矣。
【纲】仲景曰。小结胸病。正在心下。按之则痛。脉浮滑者。小陷胸汤主之。
【目】张兼善曰。从心下至少腹。石硬而痛不可近者。大结胸也。正在心下。未及腹胁。按之痛。未至石硬。小结
胸也。形症之分如此。盖大结胸者。是水结在胸腹。故其脉沉紧。小结胸者。是痰结于心下。故其脉浮滑。水结宜下。
故用甘遂、葶、杏、硝、黄等。痰结宜消。故用栝蒌、半夏等。
【纲】仲景曰。结胸症。其脉浮大者。不可下。下之则死。结胸症具。烦躁者亦死。
【目】陈士铎曰。言不可下。见下之必死也。夫结胸而加烦躁。此胃气将绝也。胃气欲绝。即
不能生津液而养心。故为死症。虽然。津液之竭。非五脏自绝。亦因结胸之故耳。是必攻其中坚。
使结胸症愈。而津液自生。死症可望更苏也。药用化结汤。
柯琴曰。阳明脉浮大。心下反硬。有热属脏者。可攻之。太阳结胸热实。脉浮大者。不可下。
盖太阳浮大。仍为表脉。恐热未实。则水未结。故不可下也。结胸是实邪。烦躁是正气虚。故亦死。
【纲】仲景曰。伤寒五六日。呕而发热者。柴胡汤症具。而以他药下之。若心下满而硬痛者。
此为结胸也。大陷胸汤主之。但满而不痛者。此为痞也。柴胡不中与之。宜半夏泻心汤。
【目】程郊倩曰。误下后有二症者。少阳为半表半里之经。不全发阳。不全发阴。故误下之变。
亦因偏于半表者。成结胸。偏于半里者。心下痞耳。此条本为半夏泻心汤而发。故只以痛不痛分
结胸痞。不及他症。
陶华曰。结胸乃下早而成。未曾下者。非结胸也。乃表邪传至于胸中。未入于腑。症虽满闷。
尚为在表。正属少阳部分。为半表半里之间。只消小柴胡加枳壳以治。不效。则以本方对小陷胸汤。
一服如神。若因下早而成者。方用陷胸汤丸。分浅深从纵治之。不宜太峻。上焦乃清道至高之分。
过下则伤元气。慎之。热实结胸。懊 烦渴心下痛。少与大陷胸汤。寒实结胸无热症。三物白
散、枳实理中丸。
【总纲】张仲景说：疾病发于阳证，却反而使用攻下法，导致热邪内陷，因此形成结胸。如果不形成结胸，仅见头部出汗，身体其余部位无汗，汗出至颈部而止，小便不通利，身体必然发黄。
【注释】陈士铎说：伤寒转变为结胸，是因为伤寒火邪正盛，此时急于进食，胃中有食物，吞咽下去却无法排出。其他脏腑因为胃中有积食，群起争扰，病势猖狂，必须用变法治疗。紧急使用一枚栝蒌，捣碎，加入一钱甘草，同煎服用。栝蒌是陷胸的良药，普通人服用它，必定会感到心中空虚失落。然而只有食积结在胸中，非芒硝、大黄、枳实、厚朴、槟榔等药不能祛除，必须得到栝蒌才能将其陷下。尤其担心其泻下作用过于猛烈，可以加入甘草以留滞药性，使其不至于过分推荡。这是变症用变法，确实比用正法治更好。
张云岐说：不发汗而反用攻下法，热邪反而内陷，寒气随着热邪进入，进入胸中必然结聚，这是因为瘀热在里的缘故。
【总纲】张仲景说：结胸病没有大热，仅头部微微出汗的，这是水饮结聚在胸胁所致，以大陷胸汤为主治方剂。
伤寒六七日，出现结胸热实证，脉象沉紧，心下疼痛，按压时像石头一样硬的，以大陷胸汤为主治方剂。结胸病患者，颈项也强直，如同柔痉的症状，通过攻下可以使病情调和，适宜用大陷胸丸。
【注释】成无己说：结胸虽然是实邪，人们都知道用陷胸汤丸攻下。但如果脉象浮大的，不可攻下，攻下会导致死亡。这是因为表邪尚未完全结实，攻下会严重损伤里气，邪气深结则死。假如结胸的形症全部具备，又加上烦躁的，更是难以治疗的疾病。
【总纲】张仲景说：疾病发于阳证而反用攻下法，热邪内陷，因此形成结胸；疾病发于阴证而反用攻下法，因此形成痞证。之所以形成结胸，是因为攻下太早的缘故。
【注释】赵嗣真说：未经过攻下后而出现心下胀满的，则有呕吐和攻下的区别。比如病人手足厥冷，脉搏突然紧涩，邪气结聚在胸中，心中胀满且烦闷，饥饿但不能进食的，病在胸中，应当用吐法。又如脉象浮大，心下反而硬，有热邪属于脏的，应当攻下，不要发汗；属于腑的，不要使小便频数。这两条就是这种情况。或者用吐法，或者用攻法，关键在于泄除邪气。如果经过攻下后出现心下胀满的，又有结胸和痞的区别。比如阳明病，虽然心下硬，但也不可攻下。经书说：阳明病心下硬满的，不可攻下。攻下后腹泻不止的会死，腹泻停止的会痊愈。这是邪气从表传里，至于心下，停留结聚成为实邪的，不可攻下，或许可以用吐法。如果尚未完全成为实邪的，则不可攻下，所以有此告诫。另外，邪气在表，不应攻下而强行攻下，邪气乘虚结聚于心下，实证的表现为硬满且疼痛，称为结胸；虚证的表现为胀满但不疼痛，称为痞。大概实邪留结，就会表现为硬和痛；虚邪留滞，就只表现为胀满而不硬痛。
柯琴说：阳指形体躯干，阴指胸中心下，不是指阴经阴证。发阳发阴，都指发热。结胸与痞，都是热证。形成痞证不说热邪内入，是因为热原发于里。误用攻下后热邪不散，因而痞硬，不可以将发阴解释为无热。如果说不是热证，泻心汤就不会使用黄芩、大黄了。
【总纲】张仲景说：小结胸病，位置正在心下，按压才疼痛，脉象浮滑的，以小陷胸汤为主治方剂。
【注释】张兼善说：从心下直到小腹，坚硬如石且疼痛不可触碰的，是大结胸。位置正在心下，未波及腹部胁肋，按压疼痛，但未到坚硬如石的，是小结胸。形症的区别如此。大概大结胸是水饮结聚在胸腹，所以脉象沉紧；小结胸是痰饮结聚在心下，所以脉象浮滑。水饮结聚宜用攻下，所以使用甘遂、葶苈子、杏仁、芒硝、大黄等；痰饮结聚宜用消散，所以使用栝蒌、半夏等。
【总纲】张仲景说：结胸病症，脉象浮大的，不可攻下，攻下会导致死亡。结胸症状具备，出现烦躁的也会死亡。
【注释】陈士铎说：说不可攻下，意思是攻下必死。结胸加上烦躁，这是胃气将要断绝的表现。胃气欲绝，就不能生津液来养心，所以是死症。虽然如此，津液的枯竭，并非五脏自绝，也是由于结胸的缘故。这必须攻伐其中的坚结，使结胸症痊愈，而津液自然生成，死症有望复苏。药物使用化结汤。
柯琴说：阳明脉浮大，心下反而硬，有热邪属于脏的，可以攻下。太阳结胸热实证，脉象浮大的，不可攻下。大概太阳脉浮大，仍为表脉，恐怕热邪尚未结实，则水饮未结，所以不可攻下。结胸是实邪，烦躁是正气虚，所以也会死。
【总纲】张仲景说：伤寒五六天，呕吐且发热的，具备柴胡汤证，却用其他药物攻下。如果心下胀满且硬痛的，这是结胸，以大陷胸汤为主治方剂。仅胀满而不疼痛的，这是痞证，不宜给予柴胡汤，适宜用半夏泻心汤。
【注释】程郊倩说：误用攻下后有两种症状，少阳是半表半里的经络，不全发阳，不全发阴，所以误用攻下后的变化，也偏于半表的形成结胸，偏于半里的形成心下痞。这一条原本是为半夏泻心汤而发的，所以只用疼痛与否来区分结胸和痞，不及及其他症状。
陶华说：结胸是由于攻下过早而形成的，未曾攻下的，不是结胸。那是表邪传至于胸中，未进入腑，症状虽然胀闷，尚在表，正属于少阳部分，处于半表半里之间，只需小柴胡汤加枳壳来治疗，无效的话，就用本方合用小陷胸汤，一服如神。如果是因攻下过早而形成的，才用陷胸汤丸，根据深浅从纵面治疗，不宜过于峻猛。上焦是清道至高之分，攻下过度会损伤元气，务必谨慎。热实结胸，懊恼烦渴心下痛，少量给予大陷胸汤；寒实结胸无热症，用三物白散、枳实理中丸。
[General Principle] Zhang Zhongjing stated: When a disease originates from a Yang syndrome and purgation is inappropriately applied, heat pathogens penetrate inward, resulting in Jie Xiong (Chest Binding). If Jie Xiong does not form, but only sweating on the head occurs with no sweat elsewhere on the body, stopping at the neck, accompanied by dysuria, jaundice will inevitably develop.
[Commentary] Chen Shiduo stated: When Shang Han (Cold Damage) transforms into Jie Xiong (Chest Binding), it is because the fire pathogen of Shang Han is intense. If food is consumed hastily, food remains in the stomach without being expelled. Other organs contend due to the food accumulation in the stomach, leading to rampant pathology. It must be treated with modified methods. Urgently use one Gualou Fructus (Trichosanthis Fructus), crushed, mixed with one qian of Gancao Radix et Rhizoma (Licorice Root), decocted together for oral administration. Gualou is an excellent herb for resolving chest binding. Even healthy people taking it may feel a sensation of emptiness in the heart. However, only when food retention binds in the chest can Mangxiao Natrii Sulfas (Glauber's Salt), Dahuang Radix et Rhizoma (Rhubarb Root), Zhishi Immature Bitter Orange Fruit, Houpo Magnolia Bark, and Binglang Areca Seed effectively dispel it; Gualou is required to sink it. One must fear its overly strong purgative effect; therefore, Gancao can be added to moderate it, preventing excessive pushing and draining. This is using modified methods for modified syndromes, which truly surpasses using standard methods.
Zhang Yunqi stated: Failure to induce sweating followed by inappropriate purgation causes heat pathogens to sink inward. Cold pathogens follow the heat inward; upon entering the chest, they bind. This is due to blood stasis and heat accumulating internally.
[General Principle] Zhang Zhongjing stated: In Jie Xiong (Chest Binding) without significant fever, but with slight sweating on the head, this indicates water retention binding in the chest and hypochondrium, primarily treated with Da Xianxiong Tang (Major Decoction to Drain the Chest).
In Shang Han (Cold Damage) lasting six or seven days, presenting as Jie Xiong heat excess syndrome with a deep and tight pulse, pain in the epigastrium, and hardness upon palpation like stone, Da Xianxiong Tang (Major Decoction to Drain the Chest) is indicated. For patients with Jie Xiong (Chest Binding) who also exhibit stiffness in the neck resembling Rou Jing (Soft Spasm), purgation harmonizes the condition; Da Xianxiong Wan (Major Pill to Drain the Chest) is appropriate.
[Commentary] Cheng Wuji stated: Although Jie Xiong (Chest Binding) involves excess pathogens, everyone knows to use Xianxiong Tang/Wan to purge it. However, if the pulse is floating and large, purgation is contraindicated; applying it leads to death. This is because exterior pathogens have not fully consolidated; purgation severely depletes the interior, and deep pathogen binding results in death. If all signs and symptoms of Jie Xiong are present, compounded by irritability (Fan Zao), it becomes an untreatable condition.
[General Principle] Zhang Zhongjing stated: When a disease originates from Yang and is inappropriately purged, heat penetrates inward, forming Jie Xiong (Chest Binding); when a disease originates from Yin and is inappropriately purged, Pi Syndrome (Epigastric Fullness/Blockage) forms. The reason Jie Xiong forms is that purgation was applied too early.
[Commentary] Zhao Sizhen stated: Epigastric fullness occurring without prior purgation distinguishes between emesis and purgation indications. For instance, if a patient has cold extremities, a suddenly tight pulse, pathogen binding in the chest, epigastric fullness with irritability, hunger but inability to eat, the pathology is in the chest and requires emesis. Conversely, if the pulse is floating and large, the epigastrium is unexpectedly hard, and heat belongs to the Zang organs, purgation is indicated without inducing sweating; if heat belongs to the Fu organs, frequent urination should be avoided. These two cases illustrate the principle. Whether using emesis or purgation, the goal is to drain the pathogen. If epigastric fullness occurs after purgation, it differentiates between Jie Xiong and Pi. For example, in Yang Ming disease, even if the epigastrium is hard, purgation is not yet indicated. The Classics state: In Yang Ming disease with epigastric hardness and fullness, do not purge. If purgation leads to unceasing diarrhea, death ensues; if diarrhea stops, recovery occurs. This describes pathogens transmitting from exterior to interior, lodging in the epigastrium and becoming excess; such cases cannot be purged, though emesis might be considered. If the condition is not fully excess, purgation is contraindicated, hence this warning. Furthermore, if pathogens are in the exterior and purgation is forced unnecessarily, pathogens enter the deficiency and bind in the epigastrium. Excess manifests as hardness, fullness, and pain, termed Jie Xiong; deficiency manifests as fullness without pain, termed Pi. Generally, excess pathogen retention causes hardness and pain, while deficient pathogen stagnation causes only fullness without hardness or pain.
Ke Qin stated: "Yang" refers to the physical body, and "Yin" refers to the chest and epigastrium, not Yin meridians or Yin syndromes. "Originating from Yang/Yin" both refer to fever. Both Jie Xiong and Pi are heat syndromes. Pi formation is described without mentioning heat penetration because the heat originates internally. Inappropriate purgation fails to dissipate heat, leading to Pi hardness; thus, "originating from Yin" cannot be interpreted as absence of heat. If it were not a heat syndrome, Xiexin Tang (Decoction to Drain the Epigastrium) would not contain Huangqin Radix (Scutellaria Root) and Dahuang.
[General Principle] Zhang Zhongjing stated: In Xiao Jie Xiong (Minor Chest Binding), the location is precisely in the epigastrium, pain occurs only upon pressure, and the pulse is floating and slippery; this is primarily treated with Xiao Xianxiong Tang (Minor Decoction to Drain the Chest).
[Commentary] Zhang Jianshan stated: Hardness like stone extending from the epigastrium to the lower abdomen, with pain so severe it cannot be touched, is Da Jie Xiong (Major Chest Binding). Location strictly in the epigastrium, not involving the abdomen or hypochondrium, with pain upon pressure but not reaching stone-like hardness, is Xiao Jie Xiong (Minor Chest Binding). The distinction in signs and symptoms is as follows. Da Jie Xiong involves water binding in the chest and abdomen, hence the deep and tight pulse; Xiao Jie Xiong involves phlegm binding in the epigastrium, hence the floating and slippery pulse. Water binding requires purgation, utilizing Gansui Radix (Kansui Root), Tinglizi Semen (Descurainia Seed), Xingren Semen (Apricot Seed), Mangxiao, and Dahuang; phlegm binding requires resolution/dissipation, utilizing Gualou and Banxia Rhizoma (Pinellia Tuber).
[General Principle] Zhang Zhongjing stated: In Jie Xiong syndromes, if the pulse is floating and large, purgation is contraindicated; applying it leads to death. If Jie Xiong symptoms are complete and accompanied by irritability, death also ensues.
[Commentary] Chen Shiduo stated: Stating "do not purge" implies that purging guarantees death. Jie Xiong combined with irritability indicates impending exhaustion of Wei Qi (Stomach Qi). When Wei Qi is about to fail, it cannot generate fluids to nourish the Heart, resulting in a fatal prognosis. Nevertheless, fluid depletion is not due to the independent failure of the Five Zang organs, but rather a consequence of Jie Xiong. One must attack the central hardness; once the Jie Xiong resolves, fluids will naturally regenerate, offering hope for revival in these fatal cases. Use Huajie Tang (Decoction to Resolve Binding).
Ke Qin stated: In Yang Ming, a floating and large pulse with unexpected epigastric hardness and internal heat belonging to Zang organs allows for purgation. However, in Taiyang Jie Xiong heat excess, a floating and large pulse contraindicates purgation. A Taiyang floating and large pulse still indicates an exterior pattern; fearing the heat is not yet consolidated and water has not bound, purgation is forbidden. Jie Xiong represents excess pathogens, while irritability represents deficiency of righteous Qi; hence, it is fatal.
[General Principle] Zhang Zhongjing stated: In Shang Han (Cold Damage) lasting five or six days, vomiting and fever indicate Chaihu Tang (Bupleurum Decoction) syndrome. If other drugs are used to purge inappropriately, and the epigastrium becomes full, hard, and painful, this is Jie Xiong, primarily treated with Da Xianxiong Tang (Major Decoction to Drain the Chest). If there is fullness without pain, this is Pi Syndrome; Chaihu Tang is not indicated. Instead, Banxia Xiexin Tang (Pinellia Decoction to Drain the Epigastrium) is appropriate.
[Commentary] Cheng Jiaoqian stated: After inappropriate purgation, two syndromes may appear. Shaoyang is the half-exterior, half-interior meridian; it does not fully manifest Yang nor fully manifest Yin. Therefore, changes following inappropriate purgation depend on whether the pathogen leans toward the half-exterior, forming Jie Xiong, or the half-interior, forming epigastric Pi. This clause originally pertains to Banxia Xiexin Tang; thus, it distinguishes Jie Xiong from Pi solely based on the presence or absence of pain, omitting other symptoms.
Tao Hua stated: Jie Xiong results from premature purgation. Cases not subjected to purgation are not Jie Xiong. They represent exterior pathogens transmitting to the chest without entering the Fu organs. Although symptoms include fullness and oppression, the pathology remains in the exterior, specifically belonging to the Shaoyang portion, situated between the half-exterior and half-interior. Treatment requires Xiaochaihu Tang (Minor Bupleurum Decoction) plus Zhike (Aurantii Fructus Immaturus). If ineffective, combine the base formula with Xiao Xianxiong Tang; one dose yields miraculous results. Only if Jie Xiong is caused by premature purgation should Xianxiong Tang/Wan be used, treating according to depth and vertical progression, avoiding overly harsh methods. The Upper Jiao is the highest clear pathway; excessive purgation damages Yuan Qi (Primal Qi); caution is essential. For Heat-Excess Jie Xiong with restlessness, thirst, and epigastric pain, administer a small dose of Da Xianxiong Tang. For Cold-Excess Jie Xiong without heat symptoms, use Sanwu Baisan (Three-Ingredient White Powder) or Zhishi Lizhong Wan (Immature Bitter Orange and Middle-Warming Pill).